A Cross-sectional Validation Study of Using NERDS and STONEES to Assess Bacterial Burden
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On 19 occasions, nurses considered the presence of infection but the researcher refuted these conclusions, indicating inconsistent assessment and potentially wrong diagnosis.
Cutting and White19 later proposed distinct sets of criteria for infection based on wound etiology. However, this type of classification is difficult to apply to practice; the value is mainly heuristic, not pragmatic. In Gardner’s20 cross-sectional descriptive study, a checklist was formulated based on validated symptoms and signs of infection including pain, exudate, delayed healing, discoloration of granulation tissue, friable granulation tissue, pocketing at the base of the wound, foul odor, and wound breakdown. Quantitative biopsy cultures >106 CFU/g of wound tissue (equivalent to heavy bacterial growth) were used as the criteria to determine the infection status of each study wound. A large number of infected wounds exhibited delayed healing and the presence of friable granulation tissue, with sensitivity values of 0.81 and 0.82, respectively. Increasing pain, increased warmth (determined by touch), and foul odor were present in fewer than half of the infected wounds with sensitivity values of 0.36, 0.18, and 0.36, respectively. Therefore, no single sign is sensitive for the diagnosis of superficial increased bacterial burden or deep infection. Gardner20 also demonstrated that perception of increasing pain was not significantly different between patients with or without diabetes in the presence of wound infection.
In their comparative study, Bowler and Davies1 evaluated the microbiology of leg ulcers (n = 74) that were categorized as either infected or noninfected based on clinical assessment. Although the evaluative criteria were not specified, the authors reported that a significantly greater mean number of bacteria was found in infected than noninfected ulcers (P <0.05). In a large cohort study (n = 1,229),21 more than half (58%) of the patients with diabetes presenting with a new foot ulcer were diagnosed with infection based on two or more physical signs and symptoms: frank purulence, local warmth, erythema, lymphangiitis, edema, pain, fever, and foul smell.
None of the reviewed studies differentiated local superficial wound damage from deep or surrounding tissue infection based on observable signs. This distinction could provide timely guidance for point-of-service clinicians to decide whether topical or systemic antimicrobial agents should be selected. However, Serena et al22 cautioned about potential underdiagnosis of wound infection if the diagnosis is based solely on clinical assessment. According to their analysis of 352 patients with venous leg ulcers in a clinical trial, Serena et al22 found that 26% of the study ulcers lacked the usual visual clinical signs of infection but were deemed infected based on quantitative biopsy results. With high host resistance, even high numbers of bacteria may be unable to damage host tissue (no clinical infection or delayed healing).
Another issue is that the identified individual clinical signs used to determine infection are tenuous and lack standardized definition. Greenwald et al’s23 evaluative study of 115 wounds determined the overall agreement on the presence of wound infection between two trained assessors was not always consistent (kappa = .57). In preparing the current study, Woo and Sibbald surmise that the relatively low concordance rate may be explained by the lack of clear definitions of the classical signs, leading to differing perceptions and interpretation of infection status.
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